How the Military Creates a ‘Perfect Storm’ for Eating Disorders (Updated)

UPDATE, May 9, 1:10 p.m.: On May 8, RH Reality Check received a response to a FOIA request from the U.S. Air Force, which reported that, between 2007 and 2012, 865 service members were diagnosed and treated for an eating disorder. During this time, six service members diagnosed with bulimia were discharged without benefits, while 16 service members were discharged with severance pay and 23 service members retired (14 members returned to duty). Of those service members diagnosed with anorexia, seven returned to duty, seven were discharged without benefits, and seven were discharged without severance pay. Eight service members diagnosed with anorexia retired.

When Theresa Larson was 24 years old, she was already leading over 50 Marines through the trenches of war.

It was September 2005. Larson and her combat engineer platoon were deployed to Iraq’s Sunni Triangle, just northwest of Baghdad, in support of Operation Iraqi Freedom III. As First Lieutenant, she oversaw her Marines as they executed conflict efforts in a highly volatile region during one of the United States’ bloodiest wars.

Larson was only in the Marines Corps for a year when she picked up her platoon in 2004, and for two years when she made First Lieutenant. But, as a high performer by nature, her swift rise through the ranks of one of the military’s toughest branches is unsurprising. She excelled in sports and academics during her teenage years in Seattle, revolving her confidence around the recognition she gained. It was a drive toward excellence she continued as a student, Division 1 collegiate softball player, and Naval Reserve Officers’ Training Corps (NROTC) cadet at Villanova University in Pennsylvania.

But being on a battlefield thousands of miles away from home took its toll on her body and mind. The combat environment she was accustomed to became even more extreme—“pressure on steroids,” as she described it.

The second most common eating disorder among women, bulimia is defined by recurring episodes of excessive eating (binging) followed by “compensatory behaviors” like self-induced vomiting, digestive supplement abuse, and extreme exercise meant to offset the effects of consuming large amounts of food (purging). Like anorexia nervosa, if left untreated, bulimia can be life-threatening.

“I would find ways to be able to [vomit] because it was like a release for me,” said Larson, one of seven female veterans chronicling their stories for the book, Phoenix: Women Warriors on Resilience, Recovery, and Triumph, which will be published this year. “Bulimia was like getting it out of my system.”

Still, no one around her knew about her eating disorder, she says, despite the telltale swelling around her jaw.

Larson’s struggle with bulimia is not uncommon among service members. Although eating disorders affect 20 million women and ten million men in the United States each year, according to the National Eating Disorders Association (NEDA), studies show a greater prevalence of some eating disorders among military service members.

A 2001 study published in Military Medicine found that, across four of the five military branches, female soldiers were likely to suffer from bulimia at nearly six times the rate of the general population—or 8.1 percent, compared to 1.5 percent of women and 0.5 percent of men—with higher numbers among female Marines (15.9 percent). The same study showed 1.1 percent of female soldiers suffered from anorexia and 62.8 percent suffered from eating disorders not otherwise specified (ED-NOS)—a rate slightly higher than that of civilian women.

In a way, the military can create a perfect storm for triggering an eating disorder, says Dr. John Dolores, executive director of Center for Hope of the Sierras, a ten-bed residential eating disorder treatment center in Reno, Nevada. The emphasis on discipline, rank, and teamwork, combined with rule-based conducts, regimented eating, and grueling physical training mirrors the mindset often associated with eating disorders: a controlling, compulsive strive for perfectionism that thrives “under rules.”

Dr. Kim Dennis, CEO and medical director of Timberline Knolls Residential Treatment Center, agrees. As a board-certified psychiatrist working with active-duty and veteran female soldiers, Dennis has observed firsthand the effects that military culture can have on triggering eating disorders, which have the highest mortality rate among mental illnesses. Last February, as part of Eating Disorders Awareness Month, she and Larson had visited the Naval Station in Norfolk, Virginia, to host a seminar raising awareness on the issue.

“A lot of the traits that make a good soldier are also the traits known to be associated with eating disorders,” Dennis told RH Reality Check, adding that the military’s “serve others before you serve yourself” ethos also “plays right into” the illness.

For Larson, this much is true. Only 23 years old when she first picked up her platoon, she was determined to be an exemplary leader. She was, after all, preparing 50-plus Marines for war—leading convoys and academic classes, executing engineering tasks, and conducting weapons and martial arts training on a daily basis.

But as she dedicated herself more and more to her team, Larson began to silently lose herself.

On paper, Larson was perfect. She was physically fit, consistently exceeding the female requirements for the Marine’s physical fitness test (PFT). In order to pass, a female Marine who is 26 years old or youngermust run three miles in less than 30 minutes, do a 15-second flex arm hang, or 50 crunches in two minutes.

There’s also the annual combat fitness test, which includes a timed 880-yard crash course, 300-yard shuttle run of combat-related tasks, and 30-pound ammo lifts until one’s elbows lock out.

If she could, Larson would strive to beat the tougher male PFT standards. She wanted to run as fast as the guys, to get as many pulls up as the men, because that’s what she was taught a leader “was supposed to do”—especially if you’re a female Marine. It didn’t matter how fatigued and exhausted she became from long hours of working, studying, and training every day, she “couldn’t show weakness” or if she gained weight.

“I was scared of gaining weight. I was scared to not look thin,” Larson, now a physical therapist with her own practice in San Diego, told RH Reality Check. “I was scared to not be the best … I had to do everything perfectly … to set an example for being one of the strongest female Marines.”

There’s been no comprehensive study of eating disorders among male service members, but a 1997 Military Medicine Naval study found that 6.8 percent of active duty Navy men battled bulimia, 2.5 percent struggled with anorexia, and 40.8 percent had ED-NOS. While the ratio between civilian women and men who suffer from eating disorders is ten to one, Dolores believes the burden to meet physical fitness standards “levels out the playing field” because female and male soldiers will “do whatever they can [to meet] these requirements.”

Larson doesn’t blame her battle with bulimia on the Marine Corps, though. Rather, she recognizes, as a person predisposed to disordered eating patterns during college, that the intense environment she chose to serve in contributed to the illness surfacing.

“I’m not going to sit here and point fingers, ‘Oh, it’s my fault’ or ‘Oh, it was the Marine Corps’ fault,'” Larson said. “It just was.”

Before deploying to Iraq, Larson tried to get help, but her roommate and her roommate’s friend told her to “keep it on the hush hush.” If she admitted to having bulimia, they said, then she may not deploy, or, worse, she might get discharged from the Marines. She received a similar warning from a psychiatrist she saw while on base overseas; the psychiatrist was, Larson says, ill informed about eating disorders.

It was hard, she says, to deal with her illness. She knew she was suffering, but she didn’t want it to get in the way of her deployment—of something she “worked so hard to be a part of” for the last two years.

“It really was an internal, invisible battle going on,” Larson said. “All of a sudden it was like I had to turn off that sense of taking care of myself and be like—excuse my language—‘Screw it and do it … I can’t let this disease get in my way.'”

According to the AlterNet article, the military failed to recognize the high prevalence of eating disorders in their ranks as culled by studies at the time.

Not much has changed. While survey-based studies showed significantly higher eating disorder rates among service members, a 2008 report from the U.S. Army Research Institute of Environmental Medicine examining nine years’ worth of medical information revealed conflicting numbers. The results of the review showed that only 1.76 percent of female service members were diagnosed with an eating disorder between 1998 and 2006, per data from the Defense Medical Epidemiology Database.

Despite this difference, the review’s authors noticed a pointed increase in eating disorder diagnoses throughout the years studied, with Marines comprising the highest percentage of diagnosed anorexia cases. It’s a steady pattern reflected seven years later: According to Department of Defense spokesperson Lt. Col. Cathy Wilkinson, military clinical data shows 771 new cases of eating disorder diagnoses—which includes pica disorder, rumination disorder, and psychogenic vomiting—for the 2013 fiscal year. That’s 22 cases more than the fiscal year before, which saw 749 new diagnoses. In the 2011 fiscal year, there were 728 new cases.

The authors also admitted their study faced several limitations, including that it only reflected data on members evaluated in clinics, which is an important admission to make, no matter how undermining to their research. As the authors recognized, eating disorders are complicated, serious illnesses that are widely misunderstood, underdiagnosed, and undertreatedworldwide—”thus,” they wrote, “leading to an imminent under-representation of cases being diagnosed compared to what may actually exist in the overall military.”

In Dennis’ view, both fear and the military’s hand-in-hand structure can attribute to the disparity between military medical data and survey-based studies. Unlike civilian life, where the Health Insurance Portability and Accountability Act (HIPPA) shields employers from knowing a worker’s medical history, military supervisors are directly involved in decisions about a soldier’s medical treatment, which can potentially have “very serious” career implications for a service member seeking recovery help.

This has particular poignancy for male soldiers. Since eating disorders are historically seen as a “women’s disease,” Dennis emphasized, active duty men experience more difficulty seeking treatment while working in an environment that “aggressively promotes” masculinity.

The differences between the data are at least recognized by Army medical professionals. The 2011 Combat and Operational Behavioral Health textbook, published by the U.S. Army Medical Department’s Borden Institute, states in its chapter on eating disorders that such a discrepancy can result from a variety of factors, including disordered eating resulting from attempting to meet the Physical Fitness Assessment, under-reporting due to “fear of adverse career actions,” screening out prior to enlistment or discharging when eating disorders “become evident,” and service members concealing their eating disorder in order to deploy, “because operational and combat experience can be an important step toward promotion.”

“We have been working hard at the [Department of Defense] to overcome stigma on seeking mental health, and have made a lot of positive steps towards reducing it,” Wilkinson told RH Reality Check, “but we still have more work to do.”

For Larson, the turning point came when she was leading “a huge operation” during the Iraqi mission. The execution went well, but she knew she wasn’t as alert as she could have been. Lives depended on her, but there she was, depressed, dehydrated, and malnourished.

Nearly three months after deploying, Larson decided to say something about her illness. She was “hit hard,” she says, with the realization that others were hurting—her father, who she told about the illness prior to deployment, wrote her a letter pleading she’d find help. Larson still couldn’t admit she needed to take care of herself, though—that her illness was a problem—because it was “ingrained” in her “from day one” that an excellent Marine takes “care of everyone else” first.

In late November 2005, after telling her commander about her struggle with bulimia, Larson was medically evacuated from the Iraqi war zone.

For 12 weeks, Larson underwent outpatient treatment for her illness.

During this time, she said her superiors and fellow Marines treated her like a “disappointment.” Despite her high performance and her positive reputation, she was made to feel—and did feel—like a failure for “leaving her Marines” in a combat zone, even though she was suffering with an illness.

“That was probably the hardest thing,” Larson told RH Reality Check. “It was like a big slap in the face.”

A few months later, in October 2006, Larson was honorably discharged from the Marine Corps. According to a Department of Defense document provided by Wilkinson, after a wounded or ill service member receives treatment, the military’s Medical Evaluation Board and Physical Evaluation Board will determine whether they’re reintegrated into or separated from the service—a decision that can be appealed—in a process that can last up to a year. This determination, said Wilkinson, is based solely on whether a solider is unfit to “perform the duties of the member’s office, grade, rank or rating because of disease or injury.”

Being discharged for her eating disorder still perplexes Larson. After all, she was a high-performing Marine with good fit evals and two service medals. “Maybe if I said something when I wasn’t at war, it wouldn’t have been an issue,” she told RH Reality Check, “but because I was medevac’d for it, taken out of the war zone, come back having to get treatment, I don’t know. It’s still something that very much boggles my mind.”

Larson says the road to recovery was difficult at first. After administratively separating from the Marines, Larson invested in her own treatment, paying out of pocket for therapy. But, while playing professional softball in Italy for five months in 2007, she said her bulimia symptoms were worsened by the competitive atmosphere. So, after returning in May of that year, Larson underwent additional therapy.

It was then that Larson was able to recover from bulimia. “That was when I just had enough. I’d been through enough already,” Larson told RH Reality Check. “I was able to use the tools I learned in therapy to stop the symptoms.”

Today, Larson, now 32,takes a more holistic approach to her health—living life in moderation and in much more control. She still struggles with body image issues, but she eats when she’s hungry and exercises regularly without overexertion.

“My love of training and food has improved so much. It’s not a fear for me anymore,” Larson said. “I think that really comes from the spiritual belief I have—a strong belief in who I am and loving myself for who I am.”

“This is who I am. This is what God gave me,” she said.

Out of the service for nearly eight years, Larson believes the military still has work to do in understanding eating disorders, both in how they function and how they play out in its ranks. In her work as an advocate on the issue, she says she hears stories quite similar to hers, where a soldier’s battle is treated as “a threat” and with little support.

Dolores and Dennis concur. The two experts believe a public conversation and stronger stance on supporting their soldiers are needed by the military on the issue, with more education, awareness, and studies conducted across the five branches. (The Borden Institute’s eating disorders section acknowledges the need for further research, such as recording the impact of operational conditions, identifying weight loss patterns pre- and post-deployment, and examining the link between trauma and eating disorders.)

The experts also feel the Department of Defense needs to develop a more specialized treatment plan for eating disorders. Particularly, noted Dennis, there’s an abundance of treatment centers that have programs designed to help soldiers recover from eating disorders “and serve their country to the maximum potential they have.”

“Because treatment works,” she said.

Wilkinson says that’s something service personnel are beginning to recognize. The way mental health is approached in and by the military has improved since Larson’s tour of duty. She cites as an example the increased number of behavioral and mental health professionals on staff. “The difference between 2006 and 2014,” she said, “is light years [apart].”

“Seeking help is a sign of strength,” she said. “People are seeing that.”